Policy Updates Medical Policy & Clinical GuidelinesCommercialApril 1, 2021

MCG Care Guidelines 25th Edition available

Effective July 1, 2021, we will upgrade to the 25th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), and Behavioral Health Care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

 

Goal Length of Stay (GLOS) for Inpatient & Surgical Care (ISC)

 

MCG Code

Guideline

24th Edition GLOS

25th Edition GLOS

S-152

Aortic Coarctation, Angioplasty

Ambulatory or 1 day postoperative

Ambulatory

W0016

Cardiac Septal Defect: Atrial, Transcatheter Closure

Ambulatory or 1 day postoperative

Ambulatory

S-445

Esophageal Diverticulectomy, Endoscopic

Ambulatory or 1 day postoperative

Ambulatory

S-510

Gastrectomy, Partial - Billroth I or II

4 or 6 days postoperative

5 days postoperative

S-1305

Hernia Repair (Non-Hiatal)

Ambulatory or 1 day postoperative

Ambulatory

S-1200

Pancreatectomy

5 or 7 days postoperative

6 days postoperative

S-990

Pyloroplasty and Vagotomy

4 or 6 days postoperative

4 days postoperative

W0097

Cervical Laminectomy

2 days postoperative

Ambulatory or
2 days postoperative

W0091

Lumbar Diskectomy, Foraminotomy, or Laminotomy

Ambulatory or 1 day postoperative

Ambulatory

S-530

Removal of Posterior Spinal Instrumentation

1 day postoperative

Ambulatory or
1 day postoperative

W0138

Shoulder Hemiarthroplasty

1 day postoperative

Ambulatory or
1 day postoperative

W0156

Spine, Scoliosis, Posterior Instrumentation, Pediatric

4 days postoperative

3 days postoperative

S-190

Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent

5 or 6 days postoperative

5 days postoperative

S-970

Prostatectomy, Transurethral Resection (TURP)

Ambulatory or 1 day postoperative

Ambulatory

S-1172

Urethroplasty

Ambulatory or 1 day postoperative

Ambulatory

 

New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)

 

MCG Code

Body System

Guideline Title

B-031-IP

Withdrawal Management

Withdrawal Management, Adult: Inpatient Care

B-031-IOP

Withdrawal Management

Withdrawal Management, Adult: Intensive Outpatient Program

B-031-AOP

Withdrawal Management

Withdrawal Management, Adult: Outpatient Care

B-031-PHP

Withdrawal Management

Withdrawal Management, Adult: Partial Hospital Program

B-031-RES

Withdrawal Management

Withdrawal Management, Adult: Residential Care

M-5197

Cardiology

Hypertension

M-7087

Cardiology

Peripheral Vascular Disease (PVD)

M-7095

Nephrology

Rhabdomyolysis

M-7100

Nephrology

Encephalopathy

M-5545

Thoracic Surgery

Rib Fracture

 

Anthem Customizations to MCG care guideline 25th Edition

 

Effective July 1, 2021, the following MCG care guideline 25th edition customizations will be implemented:

 

Transcranial Magnetic Stimulation, W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:

  • Need for acute TMS treatment, up to 6 weeks
  • Acute treatment course needed as indicated by (a) Initial course of treatment for major depressive disorder (severe), or (b) Relapse of symptoms after remission
  • Continuation of acute treatment, up to 6 months
  • TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
    • Maintenance TMS treatment
    • Continuation of acute TMS treatment for longer than 6 months
    • TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.

 

To view a detailed summary of customizations, visit the Clinical Guidelines page, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.


For questions, please contact the provider service number on the back of the member's ID card.

 

1049-0421-PN-CNT



PUBLICATIONS: April 2021 Anthem Provider News - Missouri